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HomeMy WebLinkAboutApplication for Permit To Maintain an Existing/New Underground Storage Facility - Permits - 1 MASSACHUSETTS AVENUE 10/7/1992 The Commonwealth of Massachusetts Department of Public Safety Division of Fire Prevention and Regulation APPLICATION FOR PERMIT TO MAINTAIN AN EXISTINGMEW UNDERGROUND TO: Head of Fire Department STORAGE FACILITY North Andover October 7 19 92 City, Town or District Date Application is hereby made for a permit to maintain an existing/new underground storage facility as required by 527 GIR 9.00: Permits. Location of property: 1-3 Massachusetts Avenue Street Address Owner of property: Patob Realty' Trust (MVO) Rill. nnnie of person, f1mi '0 1-Ixir[Itiot] Signature of owner or authorized representative; ' FEE: $ 10 . 00 (1l,G.L.A. Chapt. 148 Sec. 10A) FORIA F.P. 290 (Fire department's copy to be filed with F.P. 290 Part 2 (rev. 10190) ) 3 ft The Commonwealth of Massachusetts Department of Public Safety Division of Fire Prevention and Regulation PERMIT October 7 1992 Date TO MAINTAIN AN EXISTING/NEW UNDERGROUND STORAGE FACILITY In accordance with the provisions of 527 0111 9.26 this permit to maintain an existing/new underground storage facility is granted to: Location of property: 1-3 Massachusetts Avenue Street address Owner of ro ert P P Y: Pa,tob _Rea1t_y_ Trust (MVO,).„__,. Full name of person, firm or corporation Restrictions: MUST BE RENEWED ANNUALLY 2 7 cd 11/ s _/ Fee Paid:$ 10 . 00 (M.G.L.A. Chapt. 148 Sec. IOA) This permit will expire 10-7 19 93 FORM F.P. 290 pate 8196elure of Head of Fire bept. or appointed designee (rev, 10/9o) MIJIF' (Owner's copy to be posted at the storage facility) Department of Public Safety y Division of Fire Prevention and Regulation Notification for Underground Storage Tanks STATE USE ONLY ID NUMBER FIRE DEP7. 6y / �J Submit to: LOCAL FIRE DEPARTMENT DAIEFIECEIVED 2����Z�'i�. ❑ A. NEW FACILfTY B. AMENDED C.CLOSURE '°`' pale Entered Into Computer _ __ _` ❑ ❑_____ B. Data Entry Clerk Initials No.at tanks at facility No.of continuation sheets attached C. Owner Was Contacted to INSTRUCTIONS Clarify Responses. Comments Please type otpdnt In Ink,all items except"signature'In section V.This form must be completed for each location containing underground storage tanks. H more than five(5)tanks are owned at this location,photocopy the following sheets, and staple continuation shoots to the form. Notification b required by Federal taw for all underground tanks that 3.saptic tanks; have been used to slots regulated substances since January 1,1984,that 4.pipeline facilities(including gathering lines)regulated under the Natu rat Gas are In the prour►d as of Hay e,1988,or that are brought Into use after May 8, Pipeline Safety Act of 1968,or the Hazardous Liquid Pipeline Safety Act of 1979,or 1988.The tnfonnatlon requested Is required by Section 9002 of the Resource which is an intrastate pipeline facility regulated under State laws; Conservation and Reeovery Act,(RCRA),as amended, b.surface Impoundments,pits,ponds,or lagoons; 6.Storm water or waste water collection systems; The primary purpose of this notification program is to locate and evaluate ' 7.1tow•through process tanks; underground tanks that store or have stored petroleum or hazardous substances. S.liquid traps or associated gathering tines direcify related to oil or gas It is-expected that the information you provide will be based on reasonably production and gathering operations; available records,or In the absence or such records,your knowledge,belief,or 9.storage tanks situated in an underground area(such as a basement,cellar, recollection. . mineworking,drift,shah,or tunnel)if the storage tank Is situate upon or above the Who Must Notify?Section f;1002 of RCRA,as amended,requires that,unless surface of the floor. exempted,owners of underground tanks that store regulated substances must What Substances Are Covered?The notification requirements apply to under notify designated State or lots!agencies of the existence of their tanks.Owner ground storage tanks that contain regulated substances.This Includes any means-- substance defined as hazardous In section 101(14)of the Comprahensive a)In the case of an underground storage tank In use on November 8,1984,or Environmental Response,Compensation and Liability Act of 1980(CE RCLA),with brought Into use after that date,any person who owns an underground storage the exception of those substances regulated as hazardous waste under Subtitle C of tank used for the storage,use,or dispensing of regulated substances,and RCRA•It also Includes petroleum,e.g.,crude oil or any fracrion thereol which is b)In tltetase of any underground storage tank in use before November 8, liquid at standard conditions of temperature and pressure(60 degrees Fahrenheit land 1984.but no longer is use on that date,any person who owned such tank 14 7 pounds per square inch absolute). immediatety before the discontinuation of Its use. %hers To Norif}? Compicied natificatson lurm, khould be ant to thr addrl:- c)if the State agency to requires,any facility that has undergone any changes liken at the top 01 rhr%pagr to facility Infomtabon or tank system status(only amended tank Information needs to be Included). What Tanks'Ars Includod?Underground storage tank is defined as arry one or combination of tanks that(1)Is used to contain an accumulation of`regulated When To Notify?1.Owners o1 underground storage tanks in use or that have substances;and(2)whose volume(Including connected underground piping)Is been taken out or operation after January 1,1974,but still in the ground,must notify 10%or more beneath the ground,Some examples are underground tanks storing: by May 8,ION.2.Owners who bring underground storage tanks into use after May 1.Gasoline,used oil,or diesel fuel,and 2.industrial solvents,pesticides, 8,1986,must notify within 30 days of bringing the tanks Into use, herbicides or fumigants. Whet Tanks Ars Excluded?Tanks removed from the ground are not subject to notification.Other tanks excluded from notification are: Penahles:Any owner who knowingly falls to notify or submits false 1.farm or residential tanks of 1,100 gallons or less capacity used for storing Information shall be subject to a civil penalty not to exceed Sto,000 tot each motor W for 11ont»mmerdal purposes; tank for which notification b riot given or for which false Information Is 2.tanks used for storing heating oil for comumptive use on the premises submitted. where stored; (.OWNERSHIP OF TANK(S) It. LOCATION OF TANK(S) required ExAmples tore,pI»the�qs+�qraphle sooClon of Links by degrees,minutes,and seconds, Eli 42,a6.12 N>-e .BS,24.17W Owrw Name al lon,krdlvldut,t'udie Aperwy,or Other Enthyl -/ATt7/3 o/I k 7'Y '71t_LA4 T _-- Latitude Longitude 's5net,iadro.s 1- 3 S `ye_f i V - (It same as section I,rnark box We 1s) Stater�4 Fecsly Name orCortWny She klerrtN ,as ieabfe street Address(P.O.on not aoueptable) county A=i if 3 J _ rly t� N ✓o my MVniC ry Page 1 lK)fRiN F.P.290 (rev. iDISD) Ili, TYPE OF OWNER IV. INDIAN LANDS Tanks are located on land within an Indian Tribe or Nation: ❑ Federal Government ❑ Commercial Reservation or on other trust lands. ❑ ❑ State Government ® Private ❑ Local Government Tanks are owned by native American ❑nation,tribe,or individual. V. TYPE OF FACILITY Select the Appropriate Facility Description Gas Station Railroad Trucking/Transport X Petroleum Distributor Federal-Non-Military Utilities Air Taxi(Airline) Federal-Military Residential Aircraft Owner Industrial Farm Auto Dealership Contractor Other(Explain) VI, CONTACT PERSON IN CHARGE OF TANKS Name Job Title 1 Address Phone Number (Include Area Code) Wi I a.4t (�' ^!'r.�,` Or t'>>cl 13 l` aJ,j .�✓P � 17(fi Vlt. FINANCIAL RESPONSIBILITY I have met the financial responsibility requirements in accordance with 40 CFR Subpart H CheckAllthatApply _..,..�.�..._.--T----r._._..._.,�,.....----------T.� .,._.._ ._ — —— f� Self Insurance Guarantee State Funds Commercial Insurance Surety Bond Trust Fund Risk Retention Group 0 Letter of Credit 0 Other Method Allowed Specify ( VIII. CERTIFICATION (Read and sign after completing all sections) I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my inquiry of those Individuals Immediately responsible for obtaining the information, I believe that the submitted Information is trua,accurate, and complete. Name and official title of owner or owner's authorized representative (Print) Signature Date Signed EPA estimates public reporting burden for this form to average 30 minutes per response including time for reviewing instructions, gathering and maintaining the data needed and completing and reviewing the form. Send comments regarding this burden estimate to Chief, Information Policy Branch PM-223, U.S. Environmental Protection Agency, 401 M Street,Washington D.C. 20460, marked "Attention DRsk Officer for EPA.'This form amends the previous notification form as printed in 40 CFR Part 280, Appendix I. Page 2 IX. DESCRIPTION OF UNDERGROUND STORAGE TANKS (Complete for oach tank at this location,) Tank lclentificalion Number Tank No,—L Tank No, - Tank No,3 Tank No.6- Tank No. t, Status of Tank (mark only one) Currently in Use X Temporarily Out of Use (P--b.6 Y wf/actm EX) Permanently Out of Use (7M�b.b 0 c A sac{m U(j Amendment of Information 2. Date of Installation (mo.lyear) f 9 7 is ((I 7[� ( r� 7 l� i rj ?i t rl 7 6 3. Estimated Total Capacity(gallons) Q'Ccx �orGr.-u �'o c,c'U C' nc,U (i pG�� A. Material of Construction - (Marls all that apply) Asphalt Coated or Bare Steel > x Ca►hodically Protected Steel Epoxy Coated Steel — Composlio (Stool Willi rlbeiginss)Fiberglass Reinforced Reinforced Plastic Lined Interior — ---_ Double Wailed —� Polyethylene Tank Jacket i Concrelo Excavation Liner j Unknown Other, Please specify Has tank been repaired? Alu f�l fit ci ht o hf o 5. Piping (Material) (Mark all that apply) mare Steel Galvanized Steel i Fiberglass Reinforced Plastic. Copper Calhodicalty Protected Double Walled Secondary Containment � - ? Unknown �� 1 Other, please specify 3 1 6. Piping(Tyro) (Mark all that apply) Suction; no valve at tank _ X x Suction;valve at tank Pressure Gravity Food Has piping baon repaired? � h��' �] 0 , __� Tank Identification Number Tank No. Tank No._�— Tank No. Tank No, Tank No. .5 7. Substance Currently or Last Stored In Greatest Quantity by Volume Gasoline Diesel Gasohol Kerosene Heating Olt Used Oil Other, Please specify C� Hazardous Substance - CERCLA name and/or, CAS number -- - - - ----- ------ -- --- ------ -- --- --- -- - Mixture of Substances Please specify X. TANKS OUT OF USE,OR CHANGE IN SERVICE t. Closing of Tank A. Estimated date last used (mo./daylyear) B. Estimate date tank closed (rno./day/year) C. Tank was removed from ground ] -- - , D. Tank was closed in ground E. Tank filled with inert material Describe I , I j f _ F. Chango in service 771 iin A; „ ssrri€�i51 Completncl ",Iclilr..o of a leak dolerto[7 Pagc-4 XI. CERTIFICATION OF COMPLIANCE (COMPLETE FOR ALL NEW AND UPGRADED TANKS AT THIS LOCATION) Tank Identification Number Tank No, Tank No. Tank No. Tank No. Tank No. t. installation A. Installer certified by lank and piping manufacturers B. Installer certified or licensed by the Implementing agency C, Installation Inspected by a registered engineer D. Installation Inspected and x X X x approved by implementing agency E, Manufacturer's installation check- lists have been completed F. Another method allowed by State f� agency. Please specify. I 2. Release Detection(Mark all that apply) TANK PIPING TANK PIPING TANK PIPING TANK PIPING. TANK PIPING A, Manual tank gauging R. Tank lightness testing ! LZ C. Inventory controls D. Automatic tank gauging I-' monitoring 0 F. Groundwater monitoring F G. Interstitial monitoring double walled 0 F 0 tank/piping H. Interstitial monitoring/secondary EJ containment I. Automatic line leak detectors 0 E J. Line tightness testing 0 -- --- K. Other method allowed by Ll Implementing Agency. Please specify. 3. Spill and Overfill Protection A. Ovoriill device Installed f. Spill device installed �J x OA1I-1: 1 certify the information concerning installation that is provided in section X is true to the best of my belief and knowledge. Installer: _Na1e _ Signature Date _._--------__...�__ Position_.__..�_.__ Company Page 5 IX. DESCHJPTJON OF UNDERGROUND STORAGE TANKS (Comploto for each tank at this location,) Tank fdontiticalion Number rink Na. Tank No. Tank No, 'rank No, 'rank No, 1. Status of Tank (11)8d<Only ono) Currently in Use El—=71 Tomporwily Out of Uso (R----4�,Is la-t e x ti VI E —1 Pormanontly Out of Us© JOW—b-u M-1.k#-IX j Arnondment of Information I E 2. Dato of Installation (mo./yoar) 3. Eshmatod Total Capacity(gallons) CO 4. Material of Cons1toclion (Mark all that apply) Asphalt Coated or Baro Steel Cathodically Protected Stool Epoxy Coated Steel Compo'sito ('slool M111 1-1boloin-1n) I Fiberglass Reinforced Plastic Lined Interior Double Waflad Polyethylene 'rank Jacket Concrete Excavation 1.1nor Unknown Other, Pileaso specify A Has tank boon repaired? 5.4�qAnq Mat (Mark all that apply) Bare Sloe Galvanized Stool. Fiberglass Hoinforcod Plastic copper Cathodic,ally Protected Double Walled 1—= Socondaiy Containment Unknown iJther, !'lease spocify ------------------ Pipinq ypo) WhIk ail ilml ill)ply) W VZAIVO JAI I F "md;,)11: vtflw at t"mk ........... piping b',ion ................... P;s Ho alim .1 Oil Hazardous S'ubstimcri GAS numbw - ` Ploaso spocifyKTANKS OUT OF USE. OR CHANGE IN SERVICE ' 1. Closing of Tank A, Estimated date last used 13. Estimala date tank closed C. 'Tank was romovod Ifom ground 1). Tank was closed in ground Dascfibo ` ^ ' ' ' ' ^ ` ` ' - .`� ` - -' oxou( n |vokdM*wud ---------- ---- V,on4 r XI. CERTIFICATION OF COMPLIANCE (COMPLETE. FOR-ALL NEW AND UPGRADED TANKS AT THIS LOCATION) Tank Idontilicalion Number Tank No. Tank No. Tank No. Tank No. Tank No. t. Installation A. Instalior cortifiod by tank and ---- piping manufacturersL—_ - 13. Insiallor corlifiod or liconsod by the �� f implementing agency C. Installation inspected by a r I togisletod enginoor D. Installation inspected and approved by implementing agency __.. E. Manufacturor's installation chock- lists have boon complotedF. Another rnethod allowed by State ll r agency, Ploaso specify. 2. Holoase Detection (Mark all that apply) TANK PIPING TANK PIPING TANK PIPING TANK PIPING, TANK PIPING A. Manual tank gauging 01=1 B. Tank tightness testing C � I—] C, Inventory controls D. Automatic tank gauging 0 E. Vapor monitoring 0. 0 0 0 F, Groundwater monitoring . L G. Interstitial mnnhorin.g double walled: 0 �- -� tank/piping Ii. Interstitial monitoring/s©candary L--j 0 L— containment _� L Automatic line loak detectors El. 0 I F El L E--1 `----_-' J. Line tightness testing K. Other molhod allowed by —1 LA E—] E-] `- —" Implormonling Agoncy. Please specify. — - - 31 SI-,ill and C)vertill f'rolaclion A. O vmlill device installed 1.1. 5IY`l dovlce Installed OA l W t t;� illy tho int{7r mdion r.;om ofniflfl i[1M;ll<ifl0n that 95 plovide(f if) tincllon X is trE;(3 Io II10 hf?SI of fny bofi!f and knowl;'dOC'_ i E _ .� ...... - =7�